<script type="text/javascript" src="/js/epicrisis_ingresos.js"></script>

<div id="titulo_encabezado">
    <div style="padding: 5px;">
	<?php echo __('Registrar Nuevo Ingreso', true) ?>
    </div>
</div>

<div id="contenido_gral">
	
    <form action='/ingresos/paso2' method='post' id='frm_ingresos'>
        <h1>Seleccione un médico o especialidad:</h1>
            
            <table class='table' style='width:100%;'>
                <tr style='height:60px;'>
                    <td width="33%">
                        <div class="input text required">
                            <label for="name" class='label_grande'>1er. Nombre</label>
                            <input name="data[name]" type="text" value="<?php echo $data['name'];?>" id="name" class='input_grande' required>
                            <?php if(isset($errores['name'])){ echo $errores['name'];} ;?>
			</div>
                    </td>
                    <td width="33%">
		 	<div class="input text">
                            <label for="name2" class='label_grande'>2do. Nombre</label>
                            <input name="data[name2]" type="text" value="<?php echo $data['name2'];?>" id="name2" class='input_grande'>
			</div>
                    </td>
                    <td width="33%">
                        <div class="input text">
                            <label for="name3" class='label_grande'>Otros Nombres</label>
                            <input name="data[name3]" type="text" value="<?php echo $data['name3'];?>" id="name3" class='input_grande'>
			</div>
                    </td>
		</tr>	
		
                <tr style='height:60px;'>
                    <td>
		  	<div class="input text required">
                            <label for="lastname" class='label_grande'>1er. Apellido</label>
                            <input name="data[lastname]" type="text" value="<?php echo $data['lastname'];?>" id="lastname" class='input_grande' required>
                            <?php if(isset($errores['lastname'])){ echo $errores['lastname'];} ;?>
			</div>
                    </td>
                    <td>
		  	<div class="input text">
                            <label for="lastname2" class='label_grande'>2do. Apellido</label>
                            <input name="data[lastname2]" type="text" value="<?php echo $data['lastname2'];?>" id="lastname2" class='input_grande'>
			</div>
                    </td>
                    <td>
		  	<div class="input text">
                            <label for="lastname3" class='label_grande'>Otros Apellidos</label>
                            <input name="data[lastname3]" type="text" value="<?php echo $data['lastname3'];?>" id="lastname3" class='input_grande'>
			</div>
                    </td>
		</tr>	


		<tr>
                    <td colspan='3' style='padding-top:20px;text-align:right;'>
			<div class="input text">
                            <button type="submit" class='btn btn-primary' id='btn_enviar' style='width:220px;padding:10px;'>Guardar datos y asignar turno
                                <img src='/images/btn_loading.gif' id='enviando' style='display:none;margin-left:10px;'>
                            </button>
			</div>
                    </td>
		</tr>
	</table>

    </form>
</div>
<?php pr($data);?>